When considering the design of public health programs going forward, it is important to review recent developments in order to establish current best-practice in graduate public health education.
Challenges
Practical placements are extremely beneficial to students(10,14), as evidenced by their integration into many of the leading public health masters programs worldwide. However, this review demonstrated significant variation in practicum design, use of guidelines and accreditation between the programs reviewed. Overall, there were several interesting trends identified in the data that warrant further discussion.
Practicum Design
One interesting trend is the apparent continental discrepancy in practicum design. A significant proportion of the institutions ranked in the global top 10 for each region reviewed, especially North America, Australia and Africa, integrated a practice-based component into their GPH programs. However, many of the ‘leading’ programs screened for this review were thesis based. This was of particular note in Europe, where the trend diverges, and we see that the ‘top-ranked’ programs are all thesis based. These programs have not yet progressed to incorporate a mandatory practice requirement into their education model, when the evidence clearly indicates the many benefits of practicums. There are programs in the European context that do have a practical element however, it is clear that the European institutions diverge from the global trend in GPH program design.
Although practicums are becoming more ubiquitous in graduate public health education, as described in this paper, there is significant variation in the methods by which academic institutions integrate a practice-based component into their MPH programs. In the North American context design is highly regulated, where CEPH and PHAC have issued explicit guidelines that dictate the design of GPH practicums. However, the public health community has yet to develop a clearly defined and globally accepted set of guidelines outlining a superior practicum scheme. Ultimately, there are many different designs that achieve a similar end goal, with institutions around the world developing practice-based components that meet the needs of the communities being served and the people they intend to educate. In this way, practicums are being used as a response to the need for social accountability in health professional education(15,16). While this variation poses a logistic challenge to implementing quality measures in public health education, it also emphasizes the need to integrate flexibility into program design to ensure the needs of both students and communities served are being met.
A current example of emerging innovation in GPH practice-based education is the virtual practicum. It has been suggested as a pioneering solution to meet the needs of GPH students in distance learning programs or those who are pursuing an GPH in parallel with an existing career(17). While the virtual practicum design is not yet widely integrated into GPH practicums on a global scale, it is reasonable to anticipate that this approach will become more commonplace in years to come.
Practicum Design Guidelines
Another finding of note relates to the global variation in guidelines for practicum design. Some institutions are operating off a national standard which defines the required elements of a practice-based experience(2,3), but many are not. It is likely that the diversity of ‘practicum types’ encountered in this review is due in large part to the regional variation in design standards. For example, institutions in North America follow clear guidelines set out by CEPH & PHAC and GPH programs in India follow a national set of recommendations which inform practicum design. Conversely, the majority of programs in other centers seem to rely on community need or working group recommendations to guide the practicum design. Based on our review, it is unclear if creating an ‘international standard’ is feasible as there is such diversity in educational needs. However, there may be a role for a generic international metric outlining the core elements that must be included in order for a placement to be considered a practicum . This area merits further evaluation.
Accreditation
Accreditation often provides a clear set of guidelines defining the expectations for program design. There are multiple accrediting bodies, some being public health institutions and others general education institutions, operating both at national and international levels. It is reasonable to infer that institutions being accredited by public health bodies have programs that are more specifically tailored to the needs of public health education as opposed to those that aren’t. However, the majority of programs reviewed were not accredited at all. This variation in accreditation status raises the question of necessity of guiding principles in practicum design. Perhaps an interesting example to consider is the Canadian context. In Canada, the majority of programs are not accredited however they are required to meet the MPH practicum guidelines as defined by PHAC. This effectively has the same outcome as following criteria set by an accrediting body. Currently it is unclear if universal accreditation would be useful for GPH programs given the diverse needs profile of the global community. It remains to be seen if accreditation itself is a necessary or if the value accreditation lies in the oversight and provision of vetted guidelines. This area merits further investigation.
Current Practice
Our comprehensive review of graduate public health (GPH) practicum designs around the world has informed the development of an initial framework of recommendations based on current best practice (Table 6). The following discussion will focus on the elements identified as critical when considering the design of an GPH practicum.
Learning Contract
The learning contract (LC) is a crucial element to the success of a practicum. The LC is a memorandum of understanding between the student, academic institution and host institution that defines the objectives, expectations and deliverables necessary for successful completion of the placement(18). Practicums are often structured differently, as we have seen in our sample and there can be significant variation in the objectives defined and competencies assessed. Nonetheless, a well-designed LC is key to the success of any practicum. The goal is to clearly translate required competencies into specific objectives that will result in deliverables the student will be able to produce during their practical placement. Well-defined, specific practicum guidelines and objectives should be developed internally, based on competencies established by the university and any relevant accrediting body. These competencies must be clearly communicated to students and are used to define the aptitudes a student must acquire prior to completion of the program. Agreement on objectives is essential, not only for the students but also host institutions, in order to ensure the practicum is beneficial to all parties involved(19). In addition, the roles and responsibilities of each partner must be clearly delineated in the LC. This includes specific agreement about honoraria, data ownership, research products and authorship of publications.
Prerequisite Competency Training
In addition to the development of a clear learning contract, GPH programs should clearly outline the requirements students must meet in order to be prepared to undertake a practicum. We found that some programs clearly state the prerequisites, while in others it is inherent in the program scheduling i.e. students must complete 1 year of classes before they are able to proceed. This was a point of interest identified in our review. It highlights the institutional assumptions being made regarding ethical competence of students. While many programs emphasize prerequisites that focus on epidemiology and biostatistical analysis, there is little emphasis on the need for ethics training in practicum-based programs. This is in contrast to thesis-based programs which consistently integrate the need for ethical approval of research projects into the project authorization process.
Competency-based Training
It is important that institutions define the public health competencies that their graduates will attain following program completion. Some programs reviewed define key competencies based on frameworks created by an accrediting body such as CEPH, PHAC or APHEA(2,3,20), while others developed competencies based on internal standards. It should be noted that while the specific competencies assessed varied, there were consistent themes between accredited and non-accredited institutions. Competencies must be clearly communicated to students and are used to define the aptitudes a student must acquire prior to completion of the program. Once competencies are outlined by the institution, best practice is to use these educational outcomes to create practicum objectives. Objectives are actionable goals developed by the student in conjunction with the onsite practicum supervisor and university-based practicum coordinator. Objectives can then be used to inform the development of specific practicum deliverables i.e. what the student will achieve during the practicum placement (Table 6). Current best practice is consistent with the literature in requiring that deliverables are a) of use to the host institution and b) meet the criteria determined by the competency-based practicum objectives (21). While competency acquisition can be difficult to assess, the LC is a key tool that can be used to measure a student’s competency development over the course of the program and practicum. One of the main goals of LC implementation is to ensure that the students’ learning experience will lead to competency building consistent with program expectations.
Table (6) Relationship between competencies, objectives & deliverables in practicum design
Practicum Supervisor Requirements
The definition of supervisor requirements is another area that must be addressed in the design of a new GPH practicum. Clear definition is essential to ensure that practicum supervisors a) are qualified to supervise, b) have the skillset necessary to be a public health mentor and c) have capacity to evaluate students’ competency attainment. Many of the institutions reviewed reference the need for a preceptor, and some outline specific qualifications necessary. However, the challenge in this area is that qualifications may be highly practicum-specific, with extensive variation in qualifications between medicine, epidemiology, community intervention and program evaluation. For this reason, many programs have very vague supervisor requirements, stating that preceptors must be ‘experts in their field’. It is clear that supervisors must be qualified and that the requirements must be well defined such that a potential supervisor can be made aware of the expectations around their role in guiding the student through the practicum process. While the development of precise guidelines is effectively precluded by the extensive potential variation in practicum experience, as many practicums may take place outside the institutional setting, the creation of clear guidelines is critical to ensure both student and supervisors are well prepared to successfully complete the practicum. We recommend that institutions define supervisor requirements in a general sense, as seen in many of the North American centers reviewed . In this way, centers allow for variation in supervisor experience while ensuring that each is qualified to provide project-specific support/oversight to a student in the field.
Effective Mentorship & Evaluation
Open communication and continuous student feedback are critical to the success of practical placements. This emphasizes the importance of the role of the practicum supervisor and the need for continuous assessment (22,23). The supervisor plays a dual role in the practicum, both as a mentor and evaluator(24). It is the responsibility of the supervisor to work with the student to ensure that they are operating within the scope of their learning contract and are able to complete any stated deliverables within the timeframe agreed. We recommend conducting periodic evaluations of the students and the placement to assess if the practicum is an appropriate tool to facilitate competency building as required by the program(25). In addition, as the evaluations must be tailored to fit the design of the practicum, it is recommended that both short and long-term assessments are completed from multiple perspectives. While evaluation of student performance is essential to competency development, it is equally important that students are able to assess their supervisors and remain in contact with their home school throughout the duration of the practicum should they need support. This emphasizes the importance of the role played by the practicum coordinator. The coordinator is a designated faculty member whose role, among other things, is to ensure the lines of communication between student and institution remain open for the duration of the practicum. Based on our review, the use of periodic evaluation is commonplace in current practicum designs. In addition, many programs reviewed required assessments be carried out by key stakeholders (students, supervisors, host organization) at mid and final term. These assessments should evaluate both the placement and the student performance.
Strengths and weaknesses of this study
The major strength of this review is that it is based on a global sample of GPH programs, allowing for a unique perspective on the current practice in public health graduate program design. As this has not been done before, this work may serve as an initial foray into the evaluation of global trends in GPH educational approach. The information gathered has been used to design a proposed set of recommendations to guide future practice. This review can also be used to identify areas in GPH program design that could benefit from further evaluation.
There were a number of limitations in this review. Foremost among them, information collection was restricted by what was publicly available on program websites. In addition, programs were identified based on world ranking systems. While these systems operate off specific methodologies, it is likely discrepancies exists between the assessment algorithms which could easily lead to an incompletely representative sampling. In addition, the sample was limited to programs offering information available in English which led to the exclusion of institutions in Central and South America.